Physical performance and psychosocial status in lung cancer patients: results from a pilot study

Canadian oncology physiotherapists' perspectives of physical activity in people with advanced cancer: a mixed-methods study

BACKGROUND

Individuals with advanced cancer can benefit from physical activity (PA), but face barriers to PA participation. Physiotherapists can be well-positioned to support this patient population.

OBJECTIVE

Our objective was to describe the perspectives, practices, knowledge, and skills of oncology physiotherapists related to PA in people with advanced cancer.

METHODS

In this mixed-methods study, we recruited Canadian physiotherapists with current or recent clinical experience with advanced cancer. Phase I consisted of an online survey about views toward PA in advanced cancer and activity-related recommendations and concerns for two case scenarios. Phase II involved individual, semi-structured interviews about perspectives related to working with advanced cancer.

RESULTS

Sixty-two physiotherapists participated in the survey, of which 13 participated in interviews. Most respondents (> 85%) agreed or strongly agreed PA is important and safe for individuals with advanced cancer. Case responses highlighted cancer-related considerations (e.g. bone metastases) tailored activity recommendations, and patient-centered, interprofessional care. Interview themes included: 1) situating PA within individually meaningful goals; 2) tailored strategies to promote PA; 3) overarching roles in functional optimization and symptom management; and 4) generalized lack of awareness regarding physiotherapy.

CONCLUSION

Our findings indicate Canadian oncology physiotherapists describe knowledge of the safety and importance of PA, as well as key considerations in advanced cancer. Moreover, they highlight the importance of a patient-centered approach to support this population, particularly in facilitating safe and meaningful PA, as well as optimizing function and alleviating symptom burden. Further efforts are needed to investigate the development and integration of physiotherapy within cancer care.

A scoping review of studies exploring leisure-time physical activity in adults diagnosed with advanced cancer

OBJECTIVES

Despite improving survival rates, people with advanced cancer face several physical and psychosocial concerns. Leisure-time physical activity (LPA) has been found to be beneficial after cancer diagnosis, but little is known about the current state of research exploring LPA in advanced cancer. Our objectives were to (a) map the literature examining LPA in people with advanced cancer, (b) report on the terms used to describe the advanced cancer population within the literature, and (c) examine how the concept of LPA is operationalized within the literature.

METHOD

Our scoping review followed Arksey and O'Malley's methodological framework. We performed a search of 11 electronic databases and supplementary sources (February 2018; database search updated January 2020). Two reviewers independently reviewed and selected articles according to the inclusion criteria: English-language journal articles on original primary research studies exploring LPA in adults diagnosed with advanced cancer. Descriptive and thematic analyses were performed.

RESULTS

Ninety-two articles met our criteria. Most included studies were published in the last decade (80%) and used quantitative methods (77%). Many study populations included mixed (40%), breast (21%), or lung (17%) cancers. Stages 3-4 or metastatic disease were frequently indicated to describe study populations (77%). Several studies (68%) described LPA programs or interventions. Of these, 78% involved structured aerobic/resistance exercise, while 16% explored other LPA types.

SIGNIFICANCE OF RESULTS

This review demonstrates a recent surge in research exploring LPA in advanced cancer, particularly studies examining exercise interventions with traditional quantitative methods. There remains insufficient knowledge about patient experiences and perceptions toward LPA. Moreover, little is known about other leisure activities (e.g., Tai Chi, dance, and sports) for this population. To optimize the benefits of LPA in people with advanced cancer, research is needed to address the gaps in the current literature and to develop personalized, evidence-based supportive care strategies in cancer care.

Do older individuals who are diagnosed with cancer have worse physical performance prior to diagnosis compared to matched controls? A longitudinal cohort study

Background

Impaired physical performance is highly prevalent in older cancer patients and is associated with cancer-related outcomes such as mortality and chemotherapy-related toxicity. Physical performance might already decline prior to the cancer diagnosis due to undiagnosed disease. This study aimed to assess whether the physical performance of community-dwelling individuals prior to cancer diagnosis is worse compared to matched controls who are not diagnosed with cancer.

Methods

The study sample was selected from the Longitudinal Aging Study Amsterdam, a longitudinal study on a nationally representative sample of the Dutch older population. Physical performance of initially cancer-free individuals aged 55–84 years who were diagnosed with cancer during 10 or 20 years of follow-up was compared to the physical performance of controls who were not diagnosed with cancer. For controls, the physical performance measurements of the cycle with a median age closest to the cancer group were used. The time interval between physical performance measurements and the report of cancer was 2 to 4 years. Groups were compared using logistic and linear regression analysis.

Results

The study sample included 1735 individuals with a median age of 68.7 [interquartile range 63.3–76.4] years. During follow-up, 414 (23.9%) individuals were diagnosed with cancer. Handgrip strength, gait speed, chair stand ability, chair stand test time and ability to put on and take off a cardigan did not differ between groups. Individuals prior to cancer diagnosis were more likely to complete the tandem balance test.

Conclusions

Physical performance of individuals 2 to 4 years prior to report of cancer diagnosis is not lower compared to controls. This suggests that physical performance may not be influenced by cancer before diagnosis.

A longitudinal study of muscle strength and function in patients with cancer cachexia

PURPOSE

Patients with cancer frequently experience an involuntary loss of weight (in particular loss of muscle mass), defined as cachexia, with profound implications for independence and quality of life. The rate at which such patients' physical performance declines has not been well established. The aim of this study was to determine the change in muscle strength and function over 8 weeks in patients with already established cancer cachexia, to help inform the design and duration of physical activity interventions applicable to this patient group.

METHODS

Patients with thoracic and gastrointestinal cancer and with unintentional weight loss of > 5% in 6 months or BMI < 20 plus 2% weight loss were included. Physical and functional assessments (baseline, 4 weeks, 8 weeks) included isometric quadriceps and hamstring strength, handgrip, standing balance, 10-m walk time and timed up and go.

RESULTS

Fifty patients (32 male), mean ± SD age 65 ± 10 years and BMI 24.9 ± 4.3 kg/m², were recruited. Thoracic cancer patients had lower muscle strength and function (p < 0.05). Despite notable attrition, in patients who completed all assessments (8 thoracic and 12 gastrointestinal), there was little change in performance over 8 weeks (p > 0.05). Baseline variables did not differentiate between completers and non-completers (p > 0.05).

CONCLUSIONS

More than a third of patients with established cancer cachexia in our study were stable over 8 weeks, suggesting a subgroup who may benefit from targeted interventions of reasonable duration. Better understanding the physical performance parameters which characterise and differentiate these patients has important clinical implications for cancer multidisciplinary team practice.

Exercise behavior and physical fitness in patients with advanced lung cancer

PURPOSE

The aim of this work was to evaluate exercise behavior and physical fitness of advanced lung cancer patients shortly after primary diagnosis.

METHODS

Between November 2013 and December 2016, advanced lung cancer patients (n = 227, mean age 62.2 years) were enrolled shortly after diagnosis and 211 patients were tested for endurance capacity (six-minute walk test) and strength performance (maximum voluntary isometric contraction of upper and lower extremities). Current and previous exercise and walking behavior were assessed using a self-reported questionnaire regarding type, frequency, intensity, and duration. Paired Student's t tests were used to compare physical fitness to reference data. The relation of potential determinants with physical fitness was assessed using linear regression analysis.

RESULTS

Exercise behavior was superior in the year before diagnosis compared to the time of study enrollment. Patients reduced frequency, intensity, and duration of sports/exercise after their lung cancer diagnosis. We observed significantly lower endurance capacity (p < .01) and strength performance in lower extremities (p < .01) in male and female patients compared to age and sex-matched reference data. We found significant correlations of previous exercise and walking behavior with physical fitness shortly after diagnosis in patients with advanced lung cancer.

CONCLUSION

Patients with advanced lung cancer showed impaired physical fitness regarding endurance and strength capacity. The strong decline in participation of sports/exercise shortly after diagnosis supports early implementation of physical exercise during anti-cancer treatment.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02055508.

Skeletal muscle depletion during chemotherapy has a large impact on physical function in elderly Japanese patients with advanced non-small-cell lung cancer

Background

Elderly patient with advanced cancer is one of the most vulnerable populations. Skeletal muscle depletion during chemotherapy may have substantial impact on their physical function. However, there is little information about a direct relationship between quantity of muscle and physical function. We sought to explore the quantitative association between skeletal muscle depletion, and muscle strength and walking capacity in elderly patients with advanced non–small cell lung cancer (NSCLC).

Methods

Thirty patients aged ≥70 years with advanced NSCLC (stage III-IV) scheduled to initiate first-line chemotherapy were prospectively enrolled between January 2013 and November 2014. Lumbar skeletal muscle index (LSMI, cm²/m²), incremental shuttle walking distance (ISWD, m), and hand-grip strength (HGS, kg) were assessed at baseline, and 6 ± 2 weeks (T2) and 12 ± 4 weeks (T3) after study enrollment. Associations were analyzed using linear regression.

Results

Altogether, 11 women and 19 men with a median age of 74 (range, 70–82) years were included in the study; 24 received cytotoxic chemotherapy and 6, gefitinib. Mean ± standard deviation of LSMI, ISWD and HGS were 41.2 ± 7.8 cm²/m², 326.0 ± 127.9 m, and 29.3 ± 8.5 kg, respectively. LSMI and ISWD significantly declined from baseline to T2 and T3. HGS significantly declined from baseline to T2 and T3 only in men. Change in LSMI was significantly associated with change in HGS (β = 0.3 ± 0.1, p = 0.0127) and ISWD (β = 8.8 ± 2.4, p = 0.0005).

Conclusions

Skeletal muscle depletion accompanied with physical functional decline started in the early phase of the chemotherapy in elderly patients with advanced NSCLC. Our results suggest that there may be a need for early supportive care in these patients to prevent functional decline during chemotherapy.

Trial registration

Trial registration number: UMIN000009768

Name of registry: UMIN (University hospital Medical Information Network).

URL of registry: Date of registration: 14 January 2013.

Date of enrolment of the first participant to the trial: 23 January 2013.

Cardiorespiratory fitness and muscle strength in pancreatic cancer patients

PURPOSE

Cancer patients frequently experience reduced physical fitness due to the disease itself as well as treatment-related side effects. However, studies on physical fitness in pancreatic cancer patients are missing. Therefore, we assessed cardiorespiratory fitness and muscle strength of pancreatic cancer patients.

METHODS

We included 65 pancreatic cancer patients, mostly after surgical resection. Cardiorespiratory fitness was assessed using cardiopulmonary exercise testing (CPET) and 6-min walk test (6MWT). Hand-held dynamometry was used to evaluate isometric muscle strength. Physical fitness values were compared to reference values of a healthy population. Associations between sociodemographic and clinical variables with patients' physical fitness were analyzed using multiple regression models.

RESULTS

Cardiorespiratory fitness (VO₂peak, 20.5 ± 6.9 ml/min/kg) was significantly lower (-24%) compared to healthy reference values. In the 6MWT pancreatic cancer patients nearly reached predicted values (555 vs. 562 m). Maximal voluntary isometric contraction (MVIC) of the upper (-4.3%) and lower extremities (-13.8%) were significantly lower compared to reference values. Overall differences were larger in men than those in women. Participating in regular exercise in the year before diagnosis was associated with greater VO₂peak (p < .05) and MVIC of the knee extensors (p < .05).

CONCLUSIONS

Pancreatic cancer patients had significantly impaired physical fitness with regard to both cardiorespiratory function and isometric muscle strength, already in the early treatment phase (median 95 days after surgical resection). Our findings underline the need to investigate exercise training in pancreatic cancer patients to counteract the loss of physical fitness.

Muscle strength in breast cancer patients receiving different treatment regimes

BACKGROUND

Muscle dysfunction and sarcopenia have been associated with poor performance status, an increased mortality risk, and greater side effects in oncologic patients. However, little is known about how performance is affected by cancer therapy. We investigated muscle strength in breast cancer patients in different adjuvant treatment settings and also compared it with data from healthy individuals.

METHODS

Breast cancer patients (N = 255) from two randomized controlled exercise trials, staged 0-III and aged 54.4 ± 9.4 years, were categorized into four groups according to their treatment status. In a cross-sectional design, muscle function was assessed bilaterally by isokinetic dynamometry (0°, 60°, 180°/s) as maximal voluntary isometric contraction (MVIC) and maximal isokinetic peak torque (MIPT) in shoulder rotators and knee flexors and extensors. Additionally, muscular fatigue index (FI%) and shoulder flexibility were evaluated. Healthy women (N = 26), aged 53.3 ± 9.8 years, were tested using the same method. Analysis of covariance was used to estimate the impact of different cancer treatments on skeletal muscle function with adjustment for various clinical and socio-demographic factors.

RESULTS

Consistently, lower muscle strength was measured in shoulder and knee strength in patients after chemotherapy. On average, patients had up to 25% lower strength in lower extremities and 12-16% in upper extremities in MVIC and MIPT during cancer treatment compared with healthy women. No substantial difference between patient groups in shoulder strength, but significantly lower shoulder flexibility in patients with radical mastectomy was measured. Chemotherapy-treated patients had consistently higher FI%. No serious adverse events were reported.

CONCLUSIONS

Breast cancer patients showed markedly impaired muscle strength and joint dysfunctions before and after anticancer treatment. The significant differences between patients and healthy individuals underline the need of exercise therapy as early as possible in order to prevent or counteract the loss of muscle function after curative surgery as well as the consequences of neo-/adjuvant chemotherapy.

POSITIVE study: physical exercise program in non-operable lung cancer patients undergoing palliative treatment

Background

Patients with advanced stage non-small cell lung cancer (NSCLC) or small cell lung cancer (SCLC) often experience multidimensional impairments, affecting quality of life during their course of disease. In lung cancer patients with operable disease, several studies have shown that exercise has a positive impact on quality of life and physical functioning. There is limited evidence regarding efficacy for advanced lung cancer patients undergoing palliative treatment. Therefore, the POSITIVE study aims to evaluate the benefit of a 24-week exercise intervention during palliative treatment in a randomized controlled setting.

Methods/design

The POSITIVE study is a randomized, controlled trial investigating the effects of a 24-week exercise intervention during palliative treatment on quality of life, physical performance and immune function in advanced, non-operable lung cancer patients. 250 patients will be recruited in the Clinic for Thoracic Diseases in Heidelberg, enrolment begun in November 2013. Main inclusion criterion is histologically confirmed NSCLC (stage IIIa, IIIb, IV) or SCLC (Limited Disease-SCLC, Extensive Disease-SCLC) not amenable to surgery. Patients are randomized into two groups. Both groups receive weekly care management phone calls (CMPCs) with the goal to assess symptoms and side effects. Additionally, one group receives a combined resistance and endurance training (3x/week). Primary endpoints are quality of life assessed by the Functional Assessment of Cancer Therapy for patients with lung cancer (FACT-L, subcategory Physical Well-Being) and General Fatigue measured by the Multidimensional Fatigue Inventory (MFI-20). Secondary endpoints are physical performance (maximal voluntary isometric contraction, 6-min walk distance), psychosocial (depression and anxiety) and immunological parameters and overall survival.

Discussion

The aim of the POSITIVE trial is the evaluation of effects of a 24-week structured and guided exercise intervention during palliative treatment stages. Analysis of various outcomes (such as quality of life, physical performance, self-efficacy, psychosocial and immunological parameters) will contribute to a better understanding of the potential of exercise in advanced lung cancer patients. In contrast to other studies with advanced oncological patients the POSITIVE trial provides weekly phone calls to support patients both in the intervention and control group and to segregate the impact of physical activity on quality of life.

Trial registration

ClinicalTrials.gov NCT02055508 (Date: December 12, 2013)

Increasing physical activity and exercise in lung cancer: reviewing safety, benefits, and application

Lung cancer continues to be a difficult disease frequently diagnosed in late stages with a high mortality and symptom burden. In part because of frequent lung comorbidity, even lung cancer survivors often remain symptomatic and functionally limited. Though targeted therapy continues to increase treatment options for advanced-stage disease, symptom burden remains high with few therapeutic options. In the last several decades, exercise and physical activity have arisen as therapeutic options for obstructive lung disease and lung cancer. To date, exercise has been shown to reduce symptoms, increase exercise tolerance, improve quality of life, and potentially reduce length of stay and postoperative complications. Multiple small trials have been performed in perioperative non-small-cell lung cancer patients, although fewer studies are available for patients with advanced-stage disease. Despite the increased interest in this subject over the last few years, a validated exercise regimen has not been established for perioperative or advanced-stage disease. Clinicians underutilize exercise and pulmonary rehabilitation as a therapy, in part because of the lack of evidence-based consensus as to how and when to implement increasing physical activity. This review summarizes the existing evidence on exercise in lung cancer patients.

Cachexia in chronic obstructive pulmonary disease: new insights and therapeutic perspective

Cachexia and muscle wasting are well recognized as common and partly reversible features of chronic obstructive pulmonary disease (COPD), adversely affecting disease progression and prognosis. This argues for integration of weight and muscle maintenance in patient care. In this review, recent insights are presented in the diagnosis of muscle wasting in COPD, the pathophysiology of muscle wasting, and putative mechanisms involved in a disturbed energy balance as cachexia driver. We discuss the therapeutic implications of these new insights for optimizing and personalizing management of COPD-induced cachexia.

New targets for monitoring and therapy in Barth syndrome

PURPOSE

Barth syndrome (BTHS), an X-linked disorder caused by defects in TAZ, is the only known single-gene disorder of cardiolipin remodeling. We hypothesized that through analysis of affected individuals, we would gain a better understanding of the range of clinical features and identify targets for monitoring and therapy.

METHODS

We conducted a multidisciplinary investigation involving 42 patients with BTHS, including echocardiograms, muscle strength testing, functional exercise capacity testing, physical activity assessments, cardiolipin analysis, 3-methylglutaconic acid analysis, and review of genotype data. We analyzed data points to provide a quantitative spectrum of disease characteristics and to identify relationships among phenotype, genotype, and relevant metabolites.

RESULTS

Echocardiography revealed considerable variability in cardiac features. By contrast, almost all patients had significantly reduced functional exercise capacity. Multivariate analysis revealed significant relationships between cardiolipin ratio and left ventricular mass and between cardiolipin ratio and functional exercise capacity. We additionally identified genotypes associated with a less severe metabolic and clinical profile.

CONCLUSION

We defined previously unrecognized metabolite/phenotype/genotype relationships, established targets for therapeutic monitoring, and validated avenues for clinical assessment. In addition to providing insight into BTHS, these studies also provide insight into the myriad of multifactorial disorders that converge on the cardiolipin pathway.Genet Med 18 10, 1001-1010.